| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,937 |
835 |
$125K |
| D1120 |
Prophylaxis - child |
2,128 |
2,128 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
2,683 |
2,682 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,123 |
2,123 |
$57K |
| D4341 |
|
288 |
158 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
475 |
335 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,472 |
1,471 |
$29K |
| D1110 |
Prophylaxis - adult |
557 |
556 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
387 |
306 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
604 |
604 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
2,278 |
2,267 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,089 |
1,999 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
395 |
382 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
133 |
122 |
$6K |
| D0272 |
Bitewings - two radiographic images |
371 |
371 |
$4K |
| D2331 |
|
15 |
14 |
$2K |
| D4910 |
|
25 |
25 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$146.55 |
| D0270 |
|
26 |
26 |
$145.60 |